The explosion resulted in 15 fatalities and 260 injuries. When the incident first occurred, the media blamed the co-located Anhydrous Ammonia for the explosion. No knowledgeable person that saw the video of the explosion thought this was an ammonia fire. What you are witnessing below is not a deflagration (from Ammonia) but a detonation from Ammonia Nitrate.

During a break, I asked one of the investigators “How quickly did you know this wasn’t an Anhydrous Ammonia explosion?” His answer, “On day one!” Yet, still today we have articles blaming this explosion on Anhydrous Ammonia. I know several refrigeration plants that were inspected by OSHA and told that their inspection was caused by the incident in West, TX.

During the public comment period at the end of the night, Dr. M. Sam Mannan from the Mary Kay O’Connor Process Safety Center at Texas A&M delivered some great remarks.

“Unless we learn to make these changes happen, that is capture the lessons learned into our practices and activities, I am afraid that these well done and thoughtful investigation reports will not yield any beneficial outcome. The same is true with incidents involving other chemicals. Very few incidents involve unknown root causes or lessons learned. In fact, there is a sameness of all incidents and it seems to me that we are watching the same basic set of circumstances over and over again. The systematic root causes and lessons learned from all incidents are more or less the same. Right after any incident there is a big push to learn from the incident, and then quickly everything is forgotten and we resume business as usual.”

So, even though this wasn’t an Anhydrous Ammonia incident, what can the Ammonia refrigeration industry learn from West, TX? Here are my thoughts:

Understand that your RAGAGEP (Recognized and Generally Accepted Good Engineering Practices) evolves and so should your process.

Take the time to develop a relationship with your emergency responders and drill on the incidents you could face together.

RAGAGEP – In this incident, there were consensus standards that provided safer practices for storing the ammonia nitrate. The facility believed themselves “Grandfathered” and ignored evolving, improved practices that would have almost assured this incident couldn’t have happened. Takeaway question for you: When is the last time you updated and looked at your IIAR Ammonia Refrigeration Library?

Recommendations – The insurance carrier for the facility made several recommendations over a period of years and didn’t receive much response to them. After several years of difficulties, the insurance carrier dropped them as a client. That’s a red flag that you have some cultural problems! While none of the recommendations the insurance carrier made were likely to have directly prevented the incident, it is likely that the culture developed from fixing known problems would have led to fixing the previously mentioned RAGAGEP issues. Takeaway question for you: When is the last time you looked through your Compliance Audits, PHA, MI, Incident Investigations, etc. to make sure there aren’t some open items you could address?

Emergency Responders – There was essentially no communication to the emergency responders about the detonation hazards of ammonia nitrate. They had knowledge of the Anhydrous Ammonia and had even drilled on dealing with it, but they were completely unprepared for the possibility of an ammonia nitrate explosion. Takeaway question for you: When is the last time you had the local emergency responders out to your site for a tour and a discussion on the hazards they COULD face in an emergency?

Please consider these three things above at your facility. Your efforts could mean we get to avoid going to a future CSB event concerning your facility.

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On a personal note: The couple sitting directly in front of me lost their son, a volunteer firefighter, to the blast. One of the CSB investigators came over to talk with the family and spent a few moments discussing who he was as a person. It was a very emotional thing and I applaud the investigator for taking a little bit of time last night to acknowledge the victims as people, not just as statistics. The board started the meeting with a moment of silence for the victims, which was also appropriate and appreciated.

The CSB has had a rough few years, but what I saw last night gave me renewed hope.